=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861993263
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHCARE FOR KIDS & TEENS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2018
-----------------------------------------------------
Last Update Date | 02/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 54 MILLER PIKE
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40033-9248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-692-9015
-----------------------------------------------------
Fax | 270-692-9008
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 54 MILLER PIKE
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40033-9248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-692-9015
-----------------------------------------------------
Fax | 270-692-9008
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | JENNIFER MULLINS
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 270-692-9015
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 3004368
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 3004368
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------